"We Didn't Have the Time to Treat Them"UHP Staff

Sanitation was a primary concern. National Library of Medicine

In March of 1918, the United States Public Health Service tersely noted that an outbreak of an especially severe form of influenza in Kansas had erupted, killing a large number of young adults. The outbreak was worrisome, simply because it was an oddity.

Influenza, as most early twentieth-century physicians and public health experts knew, did not often kill. Moreover when it did kill, its victims were usually either the very young (children or babies) or the very old. Still, the outbreak appeared as nothing more than a flicker on the Public Health Service’s radar at that time.

That spring, the Public Health Service was engaged in fighting more serious threats. Pellagra, a dietary disease, was rampant in the American South and Public Health Service officials were only slowly beginning to untangle its causes and propose possible cures.

Across the country and especially in rural areas, many Americans still lacked sanitary privies and outhouses meaning that “filth diseases,” such as typhoid and hookworm, continued to plague many Americans. And while yellow fever had recently been eradicated, malaria, smallpox, bubonic plague, and polio continued to pose serious threats. In fact, that year saw outbreaks of all of these diseases, with Public Health Service officials being dispatched to contain outbreaks across the United States and its territories.

The Public Health Service was not, however, the only agency caring for the nation’s health. State and local health boards also played a crucial role in tracking and preventing the spread of diseases. But the powers of these different agencies varied widely. New York City’s public health department, for example, was staffed by some of the nation’s best physicians who had expertise in public health but in sparsely populated Nevada, the public health department was staffed on a part-time basis by doctors who lacked an expertise in public health.

The Practice of Medicine

Public Domain

Further complicating this was a limited understanding of medicine. By the turn of the century, a growing number of both laypeople and medical practitioners had come to accept the role that germs played in spreading disease. However, the actual day to day practice of medicine varied. In 1900, only about half of all states required physicians to pass an exam and to obtain a license before they could practice medicine. Unfortunately, many of these states “grandfathered” in older physicians, allowing them to continue to practice without taking an exam.

So, in 1918, if you saw a young physician, the chances were likely that you were seeing a practitioner who was well-trained and had a sophisticated understanding of disease. But if you were seeing an older physician, he might possess a sophisticated understanding of disease---or he might not.

Although medicine had become increasingly sophisticated, both folk remedies and folk healers also remained popular across the United States.

In the pre-antibiotic era, the two most effective tactics in fighting disease were vaccination and quarantines---but use of these tactics was both limited and problematic.

During the nineteenth century, courts had refused to give the federal government the right to force individuals to be vaccinated even when vaccination would prevent an epidemic. This meant that the use of vaccination to arrest or control an epidemic was often ineffective, even on those occasions when vaccination was effective against a specific disease (vaccination is not effective against every disease).

The use of quarantine was equally problematic. In the 1880s and 1890s, various states had gone to court insisting that the federal government did not have the right to impose a quarantine against a state’s wishes. Although successes in those court cases gave the federal government the right to impose a quarantine, it was deeply reluctant to do so, given the concerns of many that this impinged on Americans’ civil liberties.

Tracking Influenza

Influenza patient, 1918, National Library of Medicine

This was the background when, in late August of 1918, 106 sailors in Boston came down with a severe form of influenza and were hospitalized. Unlike the isolated outbreak in Kansas five months earlier, this outbreak spread rapidly across the city of Boston and from there to the rest of the state---and ultimately to the rest of the country. By mid-October, it was impossible to find an area of the country which was not suffering from influenza.

Ultimately, about 675,000 Americans would die from influenza.

While fictional depictions of influenza victims such as that of Lavinia Swire on Downton Abbey might seem staged, the truth was young adults were the most common victims of this pandemic. Even the labored breathing of the actress---hokey as that might appear to us in 2012---was accurate.

The suddenness with which this disease descends on the fictional characters living in Downton Abbey is also accurate as the disease spread very quickly.

Events in rural Berkely County in West Virginia illustrate the rapidity within which the disease could spread. In late September, the county was influenza free but that all changed on September 27th.

On that day, James Horvatt, a petty thief who was alleged to have forged a forty dollar check, was brought to trial before the county court. Horvatt had contracted the flu just before being jailed. On the day of his trial, he was offered a continuance because he was so ill. But he refused this potsponement and instead went to trial. Within a few days of his trial, Horvatt had died from influenza.

But even before his own death, Horvatt had spread the disease throughout the county. Three lawyers who simply engaged in proceedings elsewhere in the courthouse on the day of Horvatt's trial contracted influenza and died within three days. Three more people, the judge, the county clerk and the assistant prosecuting attorney in the Horvatt case along with their immediate families, all contracted the disease and came close to death.

While Berkeley County is unique in that we can clearly see both the first case and how the disease spread, its story was not atypical. In fact, this story, with minor variations, happened across the country during the fall of 1918.

Communities Collapse

Military hospital with influenza patients, 1918, Wikimedia

In communities across the US, social services collapsed, as doctors, mailmen, nurses, policemen, streetcar conductors, teachers, clergymen, lawyers, and people in a wide variety of occupations became ill and unable to do their jobs.

But the worst part of the disease was the death and destruction which it left in its wake: families collapsed as many young parents died.

Describing the pandemic, a nurse said, “The morgues were packed almost to the ceiling with bodies stacked one on top of another. The morticians worked day and night. You could never turn around without seeing a big red truck loaded with caskets for the train station so bodies could be sent home. We didn’t have the time to treat them.” The nurse, Josie Brown was especially troubled by both the suffering of her patients and the after effects, saying “when the [patient’s] lungs collapsed, air was trapped beneath their skin. As we rolled the dead in winding sheets, their bodies crackled–-an awful crackling noise which sounded like Rice Crispies when you pour milk over them.”

Public Health and Influenza

Burying influenza victims, 1918, Canada, Wikimedia

Faced with a pandemic that spread rapidly, the public health community and private practitioners were overwhelmed.

Some of their difficulties were shaped by the fact that although the Public Health Service monitored the spread of diseases across the country, they did not classify influenza as a reportable disease. Even in 1918 as the pandemic spread across the United States, the weekly journal of the Public Health Service, Public Health Reports, did not discuss influenza.

During the week when sailors and other early victims of influenza began to die in alarming numbers in Boston, the Public Health Reports did an exposé on rural sanitation, ignoring the influenza pandemic even as it became apparent to most Americans. And in late September, when influenza could be found pretty much everywhere in the United States, the Public Health Reports discussed the Public Health Services new campaign against veneral disease. The only outbreak of disease which was noted was a smallpox outbreak in Texas.

Only on September 27th, the day when James Horvatt spread influenza among the citizens of Berkeley Counry, West Virginia, did the Public Health Service began to require states and local health boards to report cases of influenza. The Public Health Service now began to doggedly track the spread of the disease across the country.

Of course, by that time, many of these areas were overrun as their physicians, nurses and public health experts—the people most qualified to make these assessments—had come down with influenza.

But even if medical practitioners had remained healthy, poor understanding of how influenza was spread combined with an inability to effectively treat those who came down with this new and deadly form of influenza meant that the death toll from this disease would widespread.

Sheena Morrison and Alexandra Lord who both contributed to this article developed an exhibit on the influenza pandemic of 1918-1919 while working for the Office of the Public Health Service Historian.

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